A Process-Oriented Breastfeeding Training Program for Healthcare Professionals to Promote Breastfeeding: An Intervention Study

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1 BREASTFEEDING MEDICINE Volume 7, Number 2, 2012 ª Mary A Liebert, Ic. DOI: /bfm A Process-Orieted Breastfeedig Traiig Program for Healthcare Professioals to Promote Breastfeedig: A Itervetio Study Aette Ekström, 1 Elisabeth Kylberg, 1 ad Eva Nisse 1,2 Abstract Aim: The aim of the study was to evaluate the effects of process-orieted traiig i supportive breastfeedig couselig for midwives ad postatal urses o the time lapse betwee the iitial breastfeedig sessio, itroductio of breastmilk substitutes ad solids, ad the duratio of breastfeedig. Materials ad Methods: Te muicipalities i Swede were radomized to either the itervetio or cotrol groups. The itervetio icluded a process-orieted traiig program for midwives ad postatal urses i the itervetio muicipalities. Primiparas ( = 540) livig i either a itervetio or cotrol muicipality were asked to participate i a logitudial study to evaluate the care give. Data collectio for cotrol group A (CGA) ( = 162) started before the itervetio was iitiated. Data for cotrol group B () ( = 172) were collected simultaeously with the itervetio group (IG) ( = 206). The mothers respoded to questioaires at 3 days, 3, ad 9 postpartum. Results: As a result of the process-orieted traiig program for midwives ad postatal urses, the IG mothers had a sigificatly loger duratio of exclusive breastfeedig, eve if the iitial breastfeedig sessio did ot occur withi 2 hours after birth, tha the correspodig group of CGA mothers ( p = 0.01). Fewer ifats i the IG received breastmilk substitutes (i the first week of life) without medical reasos compared with the cotrol groups ( p = 0.01). The IG ifats were sigificatly older (3.8 ) whe breastmilk substitutes were itroduced (after discharge from the hospital) compared with the ifats i the cotrol groups (CGA, 2.3, p = 0.01;, 2.5, p = 0.03). Coclusio: A process-orieted traiig program for midwives ad postatal urses was associated with a reduced umber of ifats beig give breastmilk substitutes durig the 1st week without medical reasos ad delayed the itroductio of breastmilk substitutes after discharge from the hospital. Itroductio Differet factors, such as breastfeedig kowledge ad cofidece, affect the duratio of breastfeedig. 1 3 Evidece-based iformatio is sigificat i guarateeig good quality i breastfeedig couselig, 4 ad several studies have focused o healthcare professioals breastfeedig kowledge ad attitudes. 5 Wome s expectatios of how log they would be breastfeedig i relatio to the actual breastfeedig experiece differed amog wome who plaed to breastfeed partially ad wome who plaed to breastfeed exclusively. The impact of givig a ifat food other tha breastmilk o the duratio of breastfeedig depeds o several factors, such as the ifat s age at itroductio, what is itroduced, how much, how ofte, ad how. 6 The World Health Orgaizatio recommeds that mothers should be supported to breastfeed exclusively for 6 ; thereafter, adequate ad safe complemetary foods should be combied with cotiued breastfeedig for 2 years or more. 6 I 2003, the Natioal Food Admiistratio, the Natioal Board of Health ad Welfare, ad the Miistry of Health ad Social Affairs preseted a commo recommedatio supportig mothers to exclusively breastfeed for up to 6 ; thereafter, the orgaizatios recommeded that mothers cotiue to breastfeed i combiatio with adequate complemetary foods for up to 1 year or loger, accordig to the mother s preferece. 7 To promote a exteded duratio of breastfeedig, early iitiatio of breastfeedig has bee show to be of utmost 1 School of Life Scieces, Uiversity of Skövde, Skövde, Swede. 2 Divisio of Reproductive ad Periatal Health Care, Departmet of Woma ad Child Health, Karoliska Istitutet, Stockholm, Swede. This study is registered with the Australia New Zealad Cliical Trials Registry with trial registratio umber ACTRN

2 86 EKSTRÖM ET AL. importace, 8 10 but the relatioship with professioal support is sparsely described. Child Health Care (CHC) is orgaized ito local cliics all over Swede ad gives recommedatios about feedig. The CHC also plays a importat role i how parets actually feed their ifats. At the time of this study, CHC recommeded that parets itroduce solids at 4 6 of age, with more emphasis o 4 tha o the rage of Hörell et al. 6 showed that breastmilk substitutes but ot solids limit breastfeedig duratio whe itroduced before 6. Evidece to date supports this recommedatio with exclusive breastfeedig durig the first 6, but further research i idustrialized coutries is eeded. Earlier studies show the importace of providig couselig to parets to achieve exclusive breastfeedig durig the first 6. 12,13 This study is part of a larger itervetio study that icludes a process-orieted program o breastfeedig maagemet ad promotio for midwives ad postatal urses from preatal ad child health ceters. Earlier results showed that the process-orieted traiig iflueced preatal midwives ad postatal urses to be more positive i ecouragig breastfeedig; postatal urses i particular improved their attitudes. The process-orieted traiig improved couselig attitudes, especially reducig cotrol behaviors ad icreasig facilitatig behaviors i regard to breastfeedig mothers. 14 I additio, the results showed that mothers were more satisfied with the emotioal ad iformative support provided by the midwives ad the postatal urses durig the first 9 postpartum. 15 Mothers also felt better prepared to take care of their babies eeds ad were better iformed about breastfeedig. 16 The aim The aim of the study was to evaluate the effects of processorieted traiig i supportive breastfeedig couselig for midwives ad postatal urses o the time lapse betwee the iitial breastfeedig sessio, itroductio of breastmilk substitutes ad solids, ad the duratio of breastfeedig. Hypotheses Through process-orieted traiig for preatal midwives ad postatal urses, a chaged attitude toward more facilitatig support could have the followig effects for mothers ad ifats. The followig hypotheses were tested: 1. H1: The iitiatio of breastfeedig will occur earlier, ad the itroductio of breastmilk substitutes ad solids will occur later. 2. H2: Fewer ifats will receive breastmilk substitutes (with o medical reaso) i the first week of life. 3. H3: The expected results above will affect the duratio of breastfeedig i a positive way. Subjects ad Methods Settig This study is part of a larger itervetio study (see below) that icludes a process-orieted program o breastfeedig maagemet ad promotio (Appedix), which was coducted durig i the southwest of Swede. The couty cosists of 13 muicipalities ad comprises urba, suburba, ad rural districts with 280,000 ihabitats. Approximately 2,500 births occur aually at materity cliics. The preatal ad child health ceters i the couty serve urba/suburba ad rural districts. The pregat wome meet a midwife at the preatal care ceter outside the hospital approximately eight to 11 times durig pregacy. Most wome give birth at the hospital, ad the care withi the delivery ad materity wards is provided by midwives ot kow to the woma. The average legth of hospital stay is betwee 6 hours ad 4 days, ad a child health urse from the CHC takes over resposibility for the ifat after he or she is discharged from the hospital ad cotiues util the child is 6 years of age. Itervetio Phase 1. The process-orieted traiig program for midwives ad postatal urses for support durig childbirth ad breastfeedig. Based o the fidigs of a baselie study 6,16 the 10 largest muicipalities i the selected area were paired accordig to their size ad the duratio of breastfeedig i those muicipalities. The paired muicipalities were radomly desigated to the itervetio (five muicipalities) or cotrol (five muicipalities) groups. Furthermore, preatal midwives ad postatal urses were allocated to the itervetio or cotrol groups depedig o whether the midwives ad urses work site had bee selected as a itervetio muicipality or as a cotrol muicipality. 15,19 A process-orieted traiig program 17 i breastfeedig couselig was coducted for the midwives ad postatal urses from the itervetio muicipalities from September 1999 through March 2000 (Fig. 1). The teachig program was composed of evidece-based lectures with collegial discussios o professioal stace, reflective processes, problemsolvig processes, ad practical skills i relatio to providig support durig childbirth ad breastfeedig (Appedix). Phase 2. The sample of mothers ad the data collectio procedures. The mothers icluded i this study had either bee cared for by healthcare professioals i the five itervetio muicipalities as described above or by healthcare professioals i the five cotrol muicipalities. Cosequetly, the mothers who were recruited for the study lived i either the itervetio muicipalities or the cotrol muicipalities. The mothers did ot kow if their preatal midwife ad postatal urse had take the process-orieted traiig program (itervetio group [IG]) or ot (cotrol groups). The sample size was based o results from the baselie study 6,16 to detect a differece betwee the IG group ad the cotrol groups of 1 moth of exclusive breastfeedig with b = 0.8 ad a = Before the process-orieted traiig program commeced, data were collected for a baselie group called cotrol group A (CGA) ( = 148). Data for cotrol group B () ( = 160) ad IG ( = 172) were collected simultaeously (Fig. 1). This desig allowed chages ad ay spillover effects of the itervetio to be detected over time. CGA ad were draw from the same five muicipalities. Iclusio criteria. Swedish-speakig, healthy, first-time mothers who gave birth to sigle, healthy, full-term babies delivered spotaeously, by vacuum extractio, or by

3 PROCESS-ORIENTED TRAINING AND BREASTFEEDING SUPPORT 87 FIG. 1. Flow diagram of how mothers were erolled i the study. Data were collected for questioaire umber 1 at 1 3 days postpartum from cotrol group A (CGA) from April 2000 to July 2001 ad from the itervetio group (IG) ad cotrol group B () from November 2000 to April Follow-up with questioaires umber 2 ad umber 3 occurred at 3 ad 9 postpartum, respectively. cesarea sectio were erolled. The mothers had bee cared for either by healthcare professioals i the itervetio muicipality, as described above, or by healthcare professioals i the cotrol muicipalities. Exclusio criteria. Mothers were excluded who had give birth to babies with life-threateig diseases or malformatios, for example, life-threateig illess such as very severe asphyxia. Iformatio about all mothers who fulfilled the iclusio criteria ad had bee cared for at the preatal ad child health cliics i the muicipalities selected for this study was cosecutively collected from the hospital registry, ad the mothers were ivited to participate i the study. I total, 584 mothers were recruited; of those, 480 gave their iformed coset to participate i the study (Fig. 1). Questioaires Obstetric data were collected from birth records, ad three differet questioaires were developed for follow-up at 3 days, 3, ad 9 postpartum. The caregivers i the materity wards distributed the first questioaire to participats o day 3 after childbirth. The questioaire covered sociodemographic backgroud (see Table 1), the time of the iitial breastfeedig sessio, ad whether the baby was give breastmilk substitutes durig the first week (see Table 2). The questioaires at 3 ad 9 were set to the mothers ad covered questios about breastfeedig ad the use of breastmilk substitutes ad/or itroductio of solids (see Table 3). Oe remider was set for each questioaire to those mothers who did ot respod. Mothers who had ot respoded to the questios regardig breastfeedig duratio, breastmilk substitutes, or itroductio of solids received a follow-up telephoe call. Defiitios At the time of the study, the Natioal Board of Health ad Welfare defied breastfeedig as follows: 11 Exclusive breastfeedig was defied as breastfeedig with occasioal use of water, breastmilk substitutes (ot more tha a few times), ad/or solids (ot more tha 1 tablespoo/day). Partial breastfeedig was defied as ifats who received breastmilk

4 88 EKSTRÖM ET AL. ad breastmilk substitutes (every day) ad/or solids (more tha 1 tablespoo/day). Total breastfeedig was defied as the duratio of exclusive ad partial breastfeedig. 11 The iitial breastfeedig sessio was defied as the first breastfeedig episode postpartum. Supplemetatio withi the first week for medical reasos applied to ifats who received breastmilk substitutes i the materity ward because of materal, medical ill health ad ifats at risk of havig low blood glucose levels, as well as ifats cared for i the eoatal ward or ifats who had lost more tha 10% of their birth weight. Supplemetatio withi the first week without medical reasos was defied as those ifats who received breastmilk substitutes for reasos such as that the ifat was cryig, the mother was tired, or the staff had advised the mother to give extra as she was ot producig eough milk. Itroductio of solids was defied as the time whe 1 or more tablespoos of solids daily were itroduced. Statistics For the statistical aalyses of the results, we used the Statistical Package for the Social Scieces (SPSS versio 14.0, SPSS, Ic., Chicago, IL). Cetral measuremets were preseted as mea with dispersio by SD. To test differeces amog the groups, idepedet t test, oe-way aalyses of variace, ad Tukey s Hoestly Sigificat Differet test for post hoc comparisos were performed. The v 2 test was performed o category data. Values of p 0.05 were cosidered sigificat. 20 Pilot test The three questioaires developed for this study were pilot-tested by 20 mothers for acceptability ad face validity, ad the questioaires were corrected before data collectio bega. I additio, a expert group of midwives ad pediatric urses was cosulted to establish the cotet validity of the questioaires. Thus, a few mior correctios were made to the wordig. Ethical cosideratios The Ethics Committee of the Medical Faculty of Gotheburg Uiversity, Gotheburg, Swede, approved the study. Results Respose rate ad dropouts The respose rate for the three questioaires is show i Figure 1. Sixty-oe percet of the mothers completed all three questioaires. The obstetric data for the participats ad the exteral dropouts did ot differ sigificatly (Table 1). There were o sigificat differeces regardig backgroud data, time for itroductio of supplemetary feedig (breastmilk substitutes or solids), or breastfeedig duratio betwee the mothers who had aswered just the first questioaire compared with those who had aswered all three questioaires. Sociodemographic backgroud ad obstetric data Sociodemographic backgroud ad obstetric data are show i Table 1. There were o sigificat differeces amog IG, CGA, ad with regard to age, educatioal level, or marital status. Furthermore, there was o sigificat differece amog the groups cocerig the mode of delivery. Iitiatio of breastfeedig The breastfeedig iitiatio rate was high i all groups: 90% iitiated breastfeedig withi the first 24 hours, ad 97% iitiated breastfeedig withi the first 3 days. No sigificat differeces were foud betwee IG (with 100% iitiatig breastfeedig) ad CGA ad (with 97% iitiatig breastfeedig). I the IG, 40% of mother ifat couples iitiated breastfeedig withi 2 hours of birth. The correspodig figures were 45% for CGA ad 40% for with o sigificat Table 1. Sociodemographic ad Obstetric Backgroud of Mothers i the Itervetio Group (IG) ad Cotrol Groups (CGA ad ) IG ( = 172) CGA ( = 148) ( = 160) Age (years) (SD) 26.6 (4.5) 27.2 (4.6) 27.0 (5.0) Gestatioal weeks (SD) 40.4 (1.4) 40.5 (1.4) 40.4 (1.4) Educatio (%) Compulsory school 6 (3%) 5 (3%) 3 (2%) High school 77 (37%) 73 (45%) 71 (41%) Uiversity 74 (36%) 55 (34%) 62 (36%) Other 14 (7%) 15 (9%) 21 (12%) Missig 35 (17%) 14 (9%) 15 (9%) Marital status (%) Cohabitatio (3 days postpartum) 125 (61%) 102 (63%) 118 (69%) Married 42 (20%) 43 (27%) 38 (22%) Sigle 3 (1.5%) 2 (1%) 2 (1%) Other 1 (0.5%) 3 (2%) 2 (1%) Missig 35 (17%) 12 (7%) 12 (7%) Obstetric data (%) Vagial delivery 146 (70%) 120 (74%) 129 (75%) Cesarea sectio 32 (16%) 22 (14%) 31 (18%) Vacuum extractio/forceps 28 (14%) 20 (12%) 12 (7%) Data are mea (SD) values or umber (%).

5 PROCESS-ORIENTED TRAINING AND BREASTFEEDING SUPPORT 89 differece foud amog the groups. If the iitial breastfeedig sessio did ot occur withi 2 hours after birth, the IG mothers breastfed exclusively for a sigificatly loger period tha the correspodig group of CGA mothers (df = 2, F = 4.43, p = 0.01). Amog the CGA mothers, those who breastfed withi 2 hours had a sigificatly loger duratio of exclusive breastfeedig tha those who did ot iitiate breastfeedig withi 2 hours (df = 2, F = 3.45, p = 0.03). No effect of the poit i time for first breastfeedig sessio ad duratio of exclusive breastfeedig was foud i. Itake of breastmilk substitutes durig the ifats first week of life i relatio to breastfeedig duratio Fewer IG ifats received breastmilk substitutes durig the first week without medical reasos (10%) compared with ifats i CGA (20%) ad (14%) (v 2 = 5.04, df = 1, p = 0.01, for all three groups) (Table 2). Those ifats who had received breastmilk substitutes without medical reasos had a sigificatly shorter duratio of exclusive breastfeedig compared with those ifats who did ot receive breastmilk substitutes i all groups: IG, df = 152, t = 2.4, p = 0.02; CGA, df = 116, t = 3.03, p = 0.01;, df = 130, t = 2.48, p = Fewer ifats i the IG received breastmilk substitute o oe occasio durig the first week tha ifats i both cotrol groups (IG, 0.3%; CGA, 2.3%;, 2.6%; p = 0.005). There were o sigificat differeces betwee ifats who received breastmilk substitute for more tha oe occasio durig the first week amog the groups. Ifat age at itroductio of breastmilk substitutes after discharge from the hospital i relatio to breastfeedig duratio The IG ifats were sigificatly older whe breastmilk substitutes were used every day, compared with the ifats i the cotrol groups: IG, 3.8 ; CGA, 2.3, p = 0.01;, 2.5 ( p = 0.03) (Table 3). There was o sigificat correlatio betwee the ifat s age at the itroductio of breastmilk substitutes every day after discharge from the hospital ad the duratio of total breastfeedig i ay of the groups. Ifat age at itroductio of solids i relatio to breastfeedig duratio There were o sigificat differeces amog the groups with regard to the ifats age at the itroductio of solid foods at more tha 1 tablespoo/day (Table 3). There was o sigificat correlatio betwee the ifat s age at the itroductio of solids ad the duratio of total breastfeedig i ay of the groups. Duratio of breastfeedig Data were aalyzed for the duratio of exclusive breastfeedig for IG (mea = 3.9, SD = 2.2 ), for CGA (mea = 3.2, SD = 1.7 ), ad for (mea = 3.5, SD = 2.0 ). There was a sigificat differece betwee IG ad CGA ( p = 0.02). Data were also aalyzed for the Table 2. Breastfeedig Duratio i Relatio to Time of the Iitial Breastfeedig Sessio ad Breastmilk Substitute Durig the Ifats First Week for Mothers i the Itervetio Group ad the Cotrol Groups IG ( = 172) CGA ( = 148) ( = 160) p value a F test IG vs. CGA IG vs. CGA vs. Exclusive breastfeedig i relatio to b Iitial breastfeedig sessio withi 2 hours (3.4) (2.2) (2.5) of birth c Iitial breastfeedig sessio after 2 hours (1.8) (2.3) (2.7) of birth c No breastmilk substitute i the first week (2.1) (2.5) (2.5) of life c Breastmilk substitute i the first week of life (2.3) (2.5) (3.0) without a medical reaso c Breastmilk substitute i the first week of life (6.4) (2.5) (2.5) with a medical reaso c Total breastfeedig i relatio to b Iitial breastfeedig sessio withi 2 hours (4.9) (4.2) (4.2) of birth c Iitial breastfeedig sessio after 2 hours (4.3) (3.5) (3.5) of birth c No breastmilk substitute i the first week (4.6) (4.8) (4.8) of life c Breastmilk substitute i the first week of life (3.7) (4.7) (3.9) without a medical reaso c Breastmilk substitute i the first week of life with a medical reaso c (6.7) (2.6) (2.6) a By Tukey s Hoestly Sigificat Differece test. b Depedet variable. c Idepedet variable.

6 90 EKSTRÖM ET AL. Table 3. Time of Itroductio (Baby s Age i Moths) of Breastmilk Substitute ad Solids i the Itervetio Group ad Cotrol Groups IG ( = 172) CGA ( = 148) ( = 160) p value a F test IG vs. CGA IG vs. CGA vs. Itroductio of breastmilk substitute (5.1) (2.7) (2.5) Itroductio of solids (0.7) (0.1) (0.1) a By Tukey s Hoestly Sigificat Differece test. duratio of ay breastfeedig for IG (mea = 7.5, SD = 4.7 ), for CGA (mea = 7.1, SD = 4.6 ), ad for (mea = 7.0, SD = 4.5 ). At 9, 23% of all mothers had stopped breastfeedig (IG, 29%; CGA, 22%;, 17%). There was o sigificat differece amog the groups with regard to the duratio of total breastfeedig. Discussio This study showed that process-orieted traiig for preatal midwives ad postatal urses was associated with specific effects o mothers feedig practices. All mothers met the same professioals i the materity ward; the oly differece was that the IG mothers had met specially traied midwives durig pregacy i cotrast to the cotrol mothers who had ot met specially traied midwives durig pregacy. A possible explaatio is that IG mothers were better iformed about good breastfeedig routies, which might result i less frequet use of breastmilk substitutes (without medical reasos) i the first week of life tha i the cotrol groups. The itroductio of breastmilk substitutes every day occurred sigificatly later i the IG tha i both cotrol groups. The itroductio of solids did ot differ amog the groups. There were o sigificat differeces amog the groups regardig the poit-i-time for the iitial breastfeedig sessio. If the CGA mothers iitial breastfeedig sessio did ot occur withi the first 2 hours after birth, the mothers breastfed exclusively for a sigificatly shorter duratio tha those who iitiated breastfeedig withi 2 hours. These results are i lie with other researchers fidigs, showig that early iitiatio of breastfeedig is associated with breastfeedig success However, a delayed iitial breastfeed did ot shorte the duratio of exclusive breastfeedig i the IG, probably because of the supportive care, which buffered the egative evet of a delayed first breastfeedig sessio. Ideed, as a result of the process-orieted traiig program for midwives ad postatal urses, a lower umber of IG ifats received breastmilk substitutes without medical reasos durig the first week of life tha the ifats i the cotrol groups. Ifats who received breastmilk substitutes without medical reasos had a sigificatly shorter duratio of exclusive breastfeedig compared with ifats who did ot receive breastmilk substitutes durig the diest week i all groups. I additio, the IG ifats were sigificatly older whe breastmilk substitutes were itroduced every day compared with the ifats i the cotrol groups. Whether this is a cause or cosequece, researchers have show that daily breastmilk substitute feedig is associated with a shorter duratio of breastfeedig. 3 Results i our study cofirm the fidigs of Hörell et al., 6 who showed that the itroductio of breastmilk substitutes decreased breastfeedig duratio, whereas itroducig solids did ot ifluece the duratio. The youger the ifats were whe they were regularly itroduced to breastmilk substitutes, the youger the ifats were whe they stopped breastfeedig. 2,6 Koehler et al. 21 evaluated differet types of utritioal couselig o ifat diet i a radomized cotrolled trial; they foud that face-toface couselig seemed to have the best effect. Earlier studies also show the importace of support with breastfeedig couselig for parets to achieve exclusive breastfeedig durig the first 6. 12,13 I the Swedish settig, where almost all ifats ad parets meet the preatal midwife ad the postatal urse, there are frequet opportuities to talk to parets ad stregthe appropriate breastfeedig support. I this study, oly 40% of the ifats had their iitial breastfeedig sessio withi 2 hours of birth. The reaso for the low iitiatio of breastfeedig withi the first 2 hours i the preset study is ot kow. We may speculate that mothers were exposed to pai medicatio durig labor such as pethidie 22 or epidural, 23 which delays the first suckig occasio. It is also possible that the mother ad her ewbor ifat were separated soo after birth i order to perform other carig tasks, such as examiatio of the ewbor or allowig the mother to have a shower, etc. If so, this idicates usatisfactory materity practices, which may result i a delayed breastfeedig start. I a previous study, we foud a much higher rate of early iitiatio of breastfeedig 9 where approximately 70% of the mothers breastfed their baby withi the first hours after birth. I the previous study, the mothers aswered the questio whe the child was betwee 9 ad 12 compared with this study, whe the questio was aswered 3 days after birth. Perhaps the differet results are caused by the differet timig of the questio. More implemetatio studies of obstacles i co-care for the mother ad her ifat i the first hours after birth are eeded, icludig a careful mappig of what actually happes with the mother ad ifat durig the first hours after birth. The methodological approach i this study with two cotrol groups, oe before the itervetio ad oe parallel with the itervetio, was helpful i order to evaluate the itervetio from a time perspective. 20 More differeces were foud whe the IG was compared with CGA (where data were collected before the itervetio) tha whe the IG was compared with (where data were collected simultaeously with the IG). The results show that chages also take place amog the cotrols whe a itervetio is beig rolled out. I midwives ad postatal urses professioal etworks, kowledge ad iformatio are shared, which easily lead to spillover effects

7 PROCESS-ORIENTED TRAINING AND BREASTFEEDING SUPPORT 91 betwee itervetio ad cotrol professioals. These results thus demostrate the value of usig a historic cotrol group, with referece to the spillover effect. 20 This itervetio should have bee stregtheed by icludig midwives ad urses workig i the delivery ad materity wards. Coclusio A process-orieted traiig program for midwives ad postatal urses was associated with reducig the umber of ifats beig give breastmilk substitutes durig the first week without medical reasos ad delayig the itroductio of breastmilk substitutes after the ifats were discharged from the hospital. Ackowledgmets This study was supported by the Skaraborg Istitute for Research ad Developmet, School of Life Scieces of the Uiversity of Skövde, Swede; the Primary Care Uit i Skaraborg ad the Sciece Committee, Cetral Hospital, Skövde, Swede; ad the Board of Research for Health ad Carig Scieces, Swedish Research Coucil, with grat umbers K P A ad K P Disclosure Statemet All authors were active i the desig, data collectio, aalysis, ad writig up of the study. All authors also read ad approved the fial mauscript. This mauscript has ot bee set to ay other scietific joural, ad there are o coflicts of iterest or fudig of the research i this mauscript. Refereces 1. Thulier D, Mercer J. Variables associated with breastfeedig duratio. J Obstet Gyecol Neoatal Nurs 2009;38: Chezem J, Friese C, Boettcher J. Breastfeedig kowledge, breastfeedig cofidece, ad ifat feedig plas: Effects o actual feedig practices. J Obstet Gyecol Neoatal Nurs 2003;32: Hoga S. Overcomig barriers to breastfeedig: Suggested breastfeedig promotio programs for commuities i easter Nova Scotia. Ca J Public Health 2001;92: Miracle D, Fredlad V. Provider ecouragemet of breastfeedig: efficacy ad ethics. J Midwifery Womes Health 2007; 52: World Health Orgaizatio. Global Strategy for Ifat ad Youg Child Feedig. World Health Orgaizatio, Geeva, Hörell A, Hofvader Y, Kylberg E. Itroductio of solids ad formula to breastfed ifats: A logitudial prospective study i Uppsala, Swede. Acta Paediatr 2001;90: Natioal Board of Health ad Welfare. Breastfeedig, Childre Bor Natioal Board of Health ad Welfare, Stockholm, De Chateau P, Holmberg H, Jakobsso K, et al. A study of factors promotig ad ihibitig lactatio. Dev Med Child Neurol 1977;19: Ekström A, Widström A-M, Nisse E. Duratio of breastfeedig i Swedish primiparous ad multiparous wome. J Hum Lact 2003;19: Salaria E, Easto P, Cater JI. Ifat feedig. Duratio of breastfeedig after early iitiatio ad frequet feedig. Lacet 1978;2: Natioal Board of Health ad Welfare. Breast-Feedig, Childre Bor Natioal Board of Health ad Welfare, Stockholm, Britto C, McCormick F, Refrew M, et al. Support for breastfeedig mothers. Cochrae Database Syst Rev 2007;(1): CD Guise JM, Palda V, Westhoff C, et al. The effectiveess of primary care-based itervetios to promote breastfeedig: Systematic evidece review ad meta-aalysis for theusprevetiveservicestaskforce.a Fam Med 2003; 1: Ekström A, Widström A, Nisse E. Process-orieted traiig i breastfeedig alters attitudes to breastfeedig i health professioals. Scad J Public Health 2005;33: Ekström A, Widström A, Nisse E. Does cotiuity of care by well-traied breastfeedig couselors improve a mother s perceptio of support? Birth 2006;33: Ekström A, Widström A-M, Nisse E. Breastfeedig support from parters ad gradmothers: perceptios of Swedish wome. Birth 2003;30: Jerlock M, Falk K, Severisso E. Academic ursig educatio guidelies: tool for bridgig the gap betwee theory, research, ad practice. Nurs Health Sci 2003;5: World Health Orgaizatio, UNICEF. Protectig, Promotig ad Supportig Breastfeedig: The Special Role of Materity Services. World Health Orgaizatio, Geeva, Ekström A, Nisse E. A mother s feeligs for her ifat are stregtheed by excellet breastfeedig couselig ad cotiuity of care. Pediatrics 2006;118: Machi D, Campbell LM, Walters S. Medical Statistics. A Textbook for the Health Scieces, 4 th ed. Wiley & Sos, Chichester, UK, Koehler S, Sichert-Hellert W, Kerstig M. Measurig the effects of utritioal couselig o total ifat diet i a radomized cotrolled itervetio trial. J Pediatr Gastroeterol Nutr 2007;45: Nisse E, Lilja G, Matthiese AS, et al. Effects of materal pethidie o ifats developig breastfeedig behaviour. Acta Paediatr 1995;84: Thorvaldse S, Roberts CL, Simpso JM, et al. Itrapartum epidural aalgesia ad breastfeedig: A prospective cohort study. It Breastfeed J 2006;11:1 24. Address correspodece to: Aette Ekström, R.N.M., Ph.D. School of Life Scieces Uiversity of Skövde Box 408 SE Skövde, Swede aette.ekstrom@his.se (Appedix follows /)

8 92 EKSTRÖM ET AL. Appedix: The Process-Orieted Traiig Program for Healthcare Professioals Defiitio of the process-orieted traiig program To chage healthcare professioals attitudes, the traiig program was based o a literature review ad collegial discussios cotaiig professioal stace, reflective processes, problem-solvig processes, ad practical skills i relatio to support durig childbirth ad breastfeedig. The healthcare professioals were traied i problem-solvig, reflectio, decisio-makig i terms of competece, ad persoal qualificatios to esure that they would be ready to meet the demads of their professio. 17 The process-orieted traiig program ivolved 7 days of lectures, ad the mai theme brought up was the participats ow breastfeedig experieces (private ad professioal), breastfeedig attitudes, breastfeedig couselig, ad collaboratio ad commuicatio betwee preatal ceters ad child health ceters i lie with World Health Orgaizatio recommedatios. 18 Midwives ad postatal urses were asked to reflect o differet areas i breastfeedig support. The supervisors o the traiig program were chose to stregthe the process betwee the healthcare ceters ad the hospital wards. The followig topics were chose by the healthcare professioals as homework: How do we protect, promote, ad support breastfeedig? How do we iform parets about parethood ad family life? How do we broade our mids i order to help parets from aother cultural backgroud? How ca you share paretal leave o a equal basis, or should we ot do this? What is attachmet, ad how do parets best support attachmet? What happes if postatal depressio occurs? Relatioships with healthcare professioals ad sigificat others. How do we support families with complicated deliveries? How do we best support paret ifat iteractio whe the ifat is cared for o the eoatal ward? How do we talk about lifestyle problems? How do we approach sigle parets?